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BACKGROUND: Recently, there has been an increase in the representation of women within the cardiothoracic surgery workforce, with discussions about gender equity garnering interest. We sought to identify whether this increase is accompanied by commensurate selection for representation at national meetings. METHODS: Online archives of the Society of Thoracic Surgeons (STS) Annual Meetings were reviewed from 2015 to 2024. Data regarding the moderator gender were abstracted. The gender distribution of moderators across the various session categories were surveyed; subgroup analyses were performed. RESULTS: During the years of study, 983 moderators were selected by STS Annual Meeting Taskforce to participate in the conference, including 218 women. The representation of women moderators demonstrated a favorable, upward trend. In 2015, 12.1% of moderators were women, with a consistent rate from 2015 to 2018. There was a noticeable rise in invited women moderators in 2019, with 25.4% of moderators being women. This proportion increased to 36.9% women in 2024. General Thoracic sessions have consistently included a greater percentage of women moderators compared to other sessions. Other topic areas, such as Education and Quality Improvement and Critical Care, transitioned to greater representation of women in recent years. CONCLUSIONS: There has been an increase over time in women moderators selected for participation in the STS Annual Meeting, with progress in gender diversity seen in most session types. While the overall proportion of women within cardiothoracic surgery remains low, the STS has increasingly worked toward encouraging inclusivity. Efforts to further support well-rounded representation are of important benefit.
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INTRODUCTION: Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications. RESULTS: Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications. DISCUSSION: There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.
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Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for â¼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.
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Anticoagulantes , Cirugía Bariátrica , Heparina , Hemorragia Posoperatoria , Tromboembolia Venosa , Humanos , Cirugía Bariátrica/efectos adversos , Estudios Retrospectivos , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/prevención & control , Femenino , Masculino , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Tromboembolia Venosa/epidemiología , Persona de Mediana Edad , Heparina/administración & dosificación , Heparina/efectos adversos , Adulto , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Incidencia , Protocolos ClínicosRESUMEN
OBJECTIVES: Although adjuvant systemic therapy (AT) has demonstrated improved survival in patients with resected non-small-cell lung cancer (NSCLC), it remains underutilized. Recent trials demonstrating improved outcomes with adjuvant immunotherapy and targeted treatment imply that low uptake of systemic therapy in at-risk populations may widen existing outcome gaps. We, therefore, sought to determine factors associated with the underutilization of AT. METHODS: The National Cancer Database (2010-2018) was queried for patients with completely resected stage II-IIIA NSCLC and stratified based on the receipt of AT. Logistic regression was used to identify factors associated with AT delivery. The Kaplan-Meier method was applied to estimate survival after propensity-matching to adjust for confounders. RESULTS: Of 37 571 eligible patients, only 20 616 (54.9%) received AT. While AT rates increased over time, multivariable analysis showed that older age [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.43-0.47], male sex (aOR 0.88, 95% CI 0.85-0.93) and multiple comorbidities (aOR 0.86, 95% CI: 0.81-0.91) were associated with decreased AT. Socioeconomic factors were additionally associated with underutilization, including public insurance (aOR 0.70, 95% CI: 0.66-0.74), lower education indicators (aOR 0.93, 95% CI: 0.88-0.97) and living more than 10 miles from a treatment facility (aOR 0.89, 95% CI: 0.85-0.93). After propensity matching, receipt of adjuvant therapy was associated with improved overall survival (median 76.35 vs 47.57 months, P ≤ 0.001). CONCLUSIONS: AT underutilization in patients with resected stage II-III NSCLC is associated with patient, institutional and socioeconomic factors. It is critical to implement measures to address these inequities, especially in light of newer adjuvant immunotherapy and targeted therapy treatment options which are expected to improve survival.
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Carcinoma de Pulmón de Células no Pequeñas , Neoplasias Pulmonares , Humanos , Masculino , Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/cirugía , Disparidades Socioeconómicas en Salud , Quimioterapia Adyuvante , Terapia Combinada , Estadificación de NeoplasiasRESUMEN
BACKGROUND: Suspicion of cancer in the Emergency Department (ED) may lead to potentially avoidable and prolonged admissions. We aimed to examine the reasons for potentially avoidable and prolonged hospitalizations after admissions from the ED for new colon cancer diagnoses (ED-dx). METHODS: A retrospective, single-institution analysis was conducted of patients with ED-dx between 2017 and 2018. Defined criteria were used to identify potentially avoidable admissions. Patients without avoidable admissions were examined for ideal length of stay (iLOS), using separate defined criteria. Prolonged length of stay (pLOS) was defined as actual length of stay (aLOS) being greater than 1 day longer than iLOS. RESULTS: Of 97 patients with ED-dx, 12% had potentially avoidable admissions, most often (58%) for cancer workup. Very little difference in demographic, tumor characteristics, or symptoms were found, except patients with potentially avoidable admissions were more functional (Eastern Cooperative Oncology Group [ECOG] score 0-1: 83% vs. 46%; p = 0.049) and had longer symptom duration prior to ED presentation {24 days (interquartile range [IQR] 7-75) vs. 7 days (IQR 2-21)}. Among the 60 patients who had necessary admissions but did not require urgent intervention, 78% had pLOS, most often for non-urgent surgery (60%) and further oncologic workup. The median difference between iLOS and aLOS was 12 days (IQR 8-16) for pLOS. CONCLUSIONS: Potentially avoidable admissions following Ed-dx were uncommon but were mostly for oncologic workup. Once admitted, the majority of patients had pLOS, most often for definitive surgery and further oncologic workup. This suggests a lack of systems to safely transition to outpatient cancer management.
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Neoplasias del Colon , Hospitalización , Humanos , Estudios Retrospectivos , Tiempo de Internación , Servicio de Urgencia en Hospital , Neoplasias del Colon/terapiaRESUMEN
OBJECTIVE: Symptomatic abdominal aortic aneurysms (sAAA) are considered surgically urgent. Recent data suggest delaying surgery allows for medical optimization without affecting outcomes. We investigated the association of the hospital day of surgery with 30 day outcomes. METHODS: Patients with infrarenal sAAA undergoing endovascular aortic repair (EVAR) between 2011 and 2018 in the American College of Surgeons National Surgery Quality Improvement Project database were included. The primary outcome was 30 day mortality. Additional outcomes included myocardial infarction, pulmonary complications, length of stay, and discharge disposition. Days-to-surgery were classified as the day of presentation (D0), day 1, day 2, days 3 and 4, days 5 to 7 (D5), and day 8 or more (D8). RESULTS: A total of 804 patients were identified. D8 patients had higher proportions of dyspnea on exertion, chronic obstructive pulmonary disease, congestive heart failure, and history of dialysis. D0 surgery appeared protective of mortality (odds ratio [OR] 0.34, p=0.0132). Each additional day increased the mortality risk (OR 1.23, p<0.001) although not within the first 4 days. There was increased mortality for patients having surgery at D5 (7.7%) and D8 (23.8%) compared with repair earlier (1%-4%, p=0.03). Bivariable analysis revealed no significant differences in secondary outcomes. Multivariable modeling revealed increased mortality for D8 versus D0 (adjusted OR of 6.8, 95% confidence interval 1.7-26.5). CONCLUSIONS: While D0 appears to have the lowest risk of mortality, EVAR for sAAA up to 4 days may not be associated with increased mortality. Further research should determine delay etiologies and whether they improve operative planning and optimization without impacting morbidity and mortality.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/complicaciones , Hospitales , Complicaciones Posoperatorias , Estudios Retrospectivos , Medición de RiesgoRESUMEN
BACKGROUND: Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS: This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS: The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION: Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.
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Obstrucción Intestinal , Laparoscopía , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/cirugía , Tiempo de Internación , Obstrucción Intestinal/cirugía , Laparoscopía/métodosRESUMEN
BACKGROUND AND OBJECTIVES: Multimodality treatment improves survival for gastric cancer (GC). However, the effect of treatment sequence by stage remains unclear. We aim to compare outcomes between patients receiving neoadjuvant(neoadj) and adjuvant chemotherapy (adj). METHODS: Nonmetastatic GC patients with clinical stage ≥ T2N0 who underwent both resection and neoadj or adj were identified using the National Cancer Database (2005-2014). Multivariable Cox regression analyses were performed on propensity score-matched (PSM) cohorts stratified by stage to compare overall survival (OS). RESULTS: We identified 11 984 patients; 55% stage I (SI), 76% stage II (SII) and 57% stage III (SIII) received neoadj. Unadjusted analysis showed worse survival among SI neoadj patients (hazard ratio [HR] 1.195, confidence interval [CI] 1.04-1.38) and improved survival for SII (HR 0.93 CI 0.87-0.998) and SIII (HR 0.75, CI 0.68-0.84). After PSM, SI patients with neoadj had worse OS with increased risk of death compared to Adj (HR 1.186, CI 1.004-1.402). SII patients had no difference in OS (HR 0.98, CI 0.91-1.07) and SIII patients had improved OS (HR 0.78, CI 0.69-0.90). CONCLUSIONS: In patients who received surgery and chemotherapy, the benefit of neoadj was limited to SIII with worse survival for SI. A clinical trial to examine the optimal sequence of chemotherapy is warranted.
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Neoplasias Gástricas , Humanos , Neoplasias Gástricas/terapia , Neoplasias Gástricas/patología , Estadificación de Neoplasias , Terapia Combinada , Quimioterapia Adyuvante , Modelos de Riesgos ProporcionalesRESUMEN
INTRODUCTION: This study examines referral patterns to surgical clinics from the emergency department and the impact of sociodemographic factors on adherence. METHODS: Patients from 2017 to 2021 were identified who had a referral placed to surgical specialties from the ED. The primary outcome was the proportion of patients who had a referral to surgery placed during an ED visit but who showed up to surgery clinic visit within 60 days of referral placement. Univariate and multivariate analysis was performed. RESULTS: Referrals were made for 45,237 patients overall and 4130 for general surgery specifically. 44% showed up to general surgery clinic visit. In univariate and multivariate analysis, those who showed up to clinic were older, tended to be female, had a lower social economic status, had Medicaid or Medicare insurance and had more comorbidities compared to those who did not show up. Asians and Hispanics were more likely to show up to clinic compared to Whites. CONCLUSIONS: Assigning navigators in the ED to follow-up with patients who are younger and healthier, with private insurances who have existing PCPs to ensure they follow up as advised is a potential targeted intervention to improve clinic adherence.
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Medicare , Pacientes Ambulatorios , Humanos , Femenino , Anciano , Estados Unidos , Servicio de Urgencia en Hospital , Medicaid , Atención Ambulatoria , Derivación y ConsultaRESUMEN
BACKGROUND: Current guidelines recommend coronary artery calcium (CAC) scoring for stratification of atherosclerotic cardiovascular disease risk only in patients with borderline to intermediate risk score by the pooled cohort equation with low-density lipoprotein-cholesterol (LDL-C) of 70 to 190 mg/dL. It remains unknown if CAC or thoracic aorta calcification (TAC), detected on routine chest computed tomography, can provide further risk stratification in patients with LDL-C≥190 mg/dL. METHODS: From a multisite medical center, we retrospectively identified all patients from March 2005 to June 2021 age ≥40 years, without established atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL who had non-gated non-contrast chest computed tomography within 3 years of LDL-C measurement. Ordinal CAC and TAC scores were measured by visual inspection. Kaplan-Meier curves and multivariable Cox-regression models were built to ascertain the association of CAC and TAC scores with all-cause mortality. RESULTS: We included 811 patients with median age 59 (53-68) years, 262 (32.3%) were male, and LDL-C median level was 203 (194-217) mg/dL. Patients were followed for 6.2 (3.29-9.81) years, and 109 (13.4%) died. Overall, 376 (46.4%) of patients had CAC=0 and 226 (27.9%) had TAC=0. All-cause mortality increased with any CAC and moderate to severe TAC. In a multivariate model, patients with CAC had a significantly higher mortality compared with those without CAC: mild hazard ratio (HR), 1.71 (1.03-2.83), moderate HR, 2.12 (1.14-3.94), and severe HR, 3.49 (1.94-6.27). Patients with moderate TAC (HR, 2.34 [1.19-4.59]) and those with severe TAC (HR, 3.02 [1.36-6.74]) had higher mortality than those without TAC. CONCLUSIONS: In patients without history of atherosclerotic cardiovascular disease and LDL-C≥190 mg/dL, the presence and severity of CAC and TAC are independently associated with all-cause mortality.
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Enfermedades de la Aorta , Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Calcificación Vascular , Adulto , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Calcio , LDL-Colesterol , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X/métodos , Calcificación Vascular/complicacionesRESUMEN
BACKGROUND: Gastric cancer lacks specific symptoms, resulting in diagnosis at later stages and high mortality. Serum pepsinogen is a biomarker for atrophic gastritis, a gastric cancer precursor, and may be useful to detect persons at increased risk of gastric cancer. METHODS: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial was conducted in the United States between 1993 and 2001. ELISA-based pepsinogen tests were conducted on prediagnostic serum samples of 105 PLCO participants who developed gastric cancer and 209 age, sex, and race-matched controls. Pepsinogen positive (PG+) was defined as pepsinogen I ≤ 70 µg/L and pepsinogen I/II ratio ≤3.0. Results of conditional logistic regression models, and sensitivity and specificity, of PG+ for gastric cancer are reported. RESULTS: Gastric cancer cases were more likely to be PG+ (31.4% vs. 5.5%, P < 0.001) at baseline than controls. Compared to PG-, PG+ was associated with an 8.5-fold increased risk for gastric cancer [95% confidence interval (CI) = 3.8-19.4]. This risk remained significant after adjusting for Helicobacter pylori, family history of gastric cancer, education, smoking, and BMI (aOR, 10.6; 95% CI, 4.3-26.2). In subgroup analysis, PG+ individuals were 11-fold more like to develop non-cardia gastric cancer (OR, 11.1; 95% CI, 4.3-28.8); conversely, they were not significantly more likely to develop cardia gastric cancer (OR, 2.0; 95% CI = 0.3-14.2). PG+ status yielded low sensitivity but high specificity for both noncardia (44.3%; 93.6%) and cardia gastric cancer (5.7%; 97.2%). CONCLUSIONS: Prediagnostic serum pepsinogen levels from a large, prospective cohort study were associated with risk of gastric cancer, particularly noncardia gastric cancer. IMPACT: PG status may identify individuals at higher risk of noncardia gastric cancer for targeted screening or interventions. See related commentary by Zhou and Huang, p. 1257.
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Pepsinógeno A , Pepsinógeno C , Neoplasias Gástricas , Biomarcadores , Estudios de Casos y Controles , Ensayos Clínicos como Asunto , Detección Precoz del Cáncer , Gastritis Atrófica , Infecciones por Helicobacter/complicaciones , Infecciones por Helicobacter/diagnóstico , Helicobacter pylori , Humanos , Masculino , Estudios Prospectivos , Próstata , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiología , Estados Unidos/epidemiologíaRESUMEN
Background Coronary artery bypass graft (CABG) surgery represents the preferred revascularization strategy for most patients with diabetes and multivessel disease. We aimed to evaluate the role of optimized, perioperative cardiometabolic targets on long-term survival in patients who underwent CABG. Methods and Results Single-institution retrospective study was conducted in patients with diabetes who underwent CABG between January 2010 and June 2018. Demographic, surgical, and cardiometabolic determinants were identified during the perioperative period. Clinical characteristics and longitudinal survival outcomes data were obtained. A total of 1534 patients with CABG were considered for analysis and 1273 met inclusion criteria. The mean age of patients was 63.3 years (95% CI, 62.7-63.8 years), and most were men (65%) and Hispanic or Latino (47%). Comorbidities included hypertension (95%) and dyslipidemia (88%). In total, 490 patients (52%) had a low-density lipoprotein cholesterol level >70 mg/dL. Furthermore, 390 patients (31%) had uncontrolled systolic blood pressure >130 mm Hg. Last, only 386 patients (29%) had a hemoglobin A1c level between 6% and 7%. At 5 years, 121 patients (10%) died. Failure to achieve goal systolic blood pressure was associated with all-cause (hazard ratio [HR], 1.573; 95% CI, 1.048-2.362 [P=0.029]) and cardiovascular (HR, 2.023; 95% CI, 1.196-3.422 [P=0.009]) mortality at 5 years post-CABG. In contrast, prescription of a statin during the perioperative interval demonstrated a protective effect for all-cause (HR, 0.484; 95% CI, 0.286-0.819 [P=0.007]) and cardiovascular (HR, 0.459; 95% CI, 0.229-0.920 [P=0.028]) mortality. There was no association between achievement of low-density lipoprotein cholesterol, triglycerides, non-high-density lipoprotein cholesterol, or hemoglobin A1c level goals and mortality risk at 5 years. Conclusions Among patients with diabetes, blood pressure control and statin therapy were the most important perioperative cardiometabolic survival determinants 5 years after CABG.
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Enfermedad de la Arteria Coronaria , Diabetes Mellitus , Inhibidores de Hidroximetilglutaril-CoA Reductasas , LDL-Colesterol , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/complicaciones , Diabetes Mellitus/tratamiento farmacológico , Femenino , Hemoglobina Glucada , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m2 (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.
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Hernia Ventral , Hernia Incisional , Hernia Ventral/complicaciones , Herniorrafia/efectos adversos , Herniorrafia/métodos , Humanos , Hernia Incisional/complicaciones , Hernia Incisional/epidemiología , Hernia Incisional/cirugía , Mejoramiento de la Calidad , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/cirugía , Estados Unidos/epidemiologíaRESUMEN
Acute type A aortic dissection requires timely diagnosis and intervention. Previous studies have examined risk factors associated with delayed diagnosis; however, the effect of socioeconomic status (SES) has not been previously studied. Our study examined the impact of various SES measures on time to diagnosis. We examined time to diagnosis in consecutive cases of acute type A aortic dissection at a single institution. SES variables included race/ethnicity, Medicaid eligibility, and residence in a zip code with an increased Distressed Communities Index-an aggregate measure of community SES. Delayed diagnosis was defined as time to diagnosis in the upper quartile of the study population (>6.6 hours). A model predicting risk factors for delayed diagnosis was created using multivariable logistic regression. Our study included 124 patients with a median time to diagnosis of 3.36 hours (interquartile range [IQR] 1.83 to 6.63). A total of 92 patients were in the nondelayed cohort (median diagnosis time of 2.59 hours, IQR 1.49 to 4.18) and 32 patients were in the delayed cohort (median diagnosis time of 15.57 hours, IQR 9.34 to 28.75). In multivariable logistic regression, residence in a high-Distressed Communities Index zip code was associated with diagnostic delay (adjusted odds ratio [aOR] 5.108, p = 0.008). Patient age (aOR 0.944, p = 0.011), chest pain at presentation (aOR 0.099, p = 0.004), back pain at presentation (aOR 0.247, p = 0.012), evidence of malperfusion syndrome (aOR 0.040, p <0.001), history of hyperlipidemia (aOR 3.507, p = 0.026), and history of congestive heart failure (aOR 0.061, p = 0.036) were also significantly associated. In conclusion, our findings suggest community-level SES affects time to diagnosis in acute type A aortic dissection.
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Disección Aórtica , Diagnóstico Tardío , Disección Aórtica/diagnóstico , Disección Aórtica/epidemiología , Humanos , Oportunidad Relativa , Estudios Retrospectivos , Factores de Riesgo , Clase Social , Factores SocioeconómicosRESUMEN
INTRODUCTION: the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. METHODS: a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. RESULTS: 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). CONCLUSION: preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.
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Pared Abdominal , Toxinas Botulínicas Tipo A , Fármacos Neuromusculares , Músculos Abdominales/cirugía , Pared Abdominal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Toxinas Botulínicas Tipo A/uso terapéutico , Hernia Ventral/cirugía , Herniorrafia , Humanos , Persona de Mediana Edad , Fármacos Neuromusculares/uso terapéutico , New York , Cuidados PreoperatoriosRESUMEN
BACKGROUND: This study compared survival between patients who had medullary thyroid cancer (MTC) treated with surgery alone and patients who underwent surgery and radiation (SRT). METHODS: Patients from the National Cancer Database (NCDB) with a diagnosis of stage 3 or 4 MTC, lymph node disease, and no distant metastases between 2008 and 2016 were studied. Kaplan-Meier analyses and log-rank statistics were used to estimate and compare overall survival between patients treated with surgery alone and those treated with SRT. Mutlivariable Cox proportional hazards models and propensity-matching were used to adjust for confounding and selection bias. RESULTS: Among 1370 patients, 1112 (81%) received surgery alone, and 258 (19%) received SRT. The hazard ratio for mortality in the SRT group was 1.784 (95% confidence interval [CI] 1.313-2.43) after multivariable adjustment for confounding variables. Furthermore, SRT remained associated with a higher mortality rate (p < 0.008) after propensity-matching in an effort to adjust for selection bias. CONCLUSIONS: This analysis of NCDB patients showed that SRT is associated with a significantly higher mortality rate among patients treated for stage 3 or 4 IV MTC with positive lymph node disease. Although this observation can be attributed to unmeasured confounders or selection bias, the cause for the profound survival differences deserves prospective evaluation, especially as adjuvant therapies for this disease continue to evolve.
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Carcinoma Neuroendocrino , Neoplasias de la Tiroides , Carcinoma Neuroendocrino/patología , Carcinoma Neuroendocrino/radioterapia , Carcinoma Neuroendocrino/cirugía , Humanos , Estimación de Kaplan-Meier , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Neoplasias de la Tiroides/radioterapia , Neoplasias de la Tiroides/cirugíaRESUMEN
OBJECTIVE: Much research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery Vascular Quality Initiative. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). RESULTS: A total of 4192 bypasses were identified. The majority utilized great saphenous vein (GSV) (76.2%), followed by polytetrafluoroethylene (10.6%), nonautologous biologic (6.5%), composite (3.3%), arm vein (2.8%), and small saphenous vein (0.6%). Compared with all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%; P < .0001) and PP (68.1%; P = .041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single-segment GSV orientations. Single-segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%; P = .0016). PP was significantly better for polytetrafluoroethylene compared with nonautologous biologic (68.4% vs 51.2%; P = .0039). PP did not significantly differ between vein cuff for prosthetic bypass compared with no vein cuff (69.1% vs 59.7%; P = .091). PP was not significantly different between single-segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%; P = .51). There were no significant differences in AFS comparing arm vein, prosthetic bypass with vein cuff, or composite grafts (67.2% vs 63.8% vs 59.3%; P = .092), as well as in PP (60.2% vs 69.1% vs 54.8%; P = .14). CONCLUSIONS: Single-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared with arm vein, as prosthetic bypass with vein cuff did not significantly differ in PP. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.
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Implantación de Prótesis Vascular , Arteria Poplítea , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Humanos , Isquemia/cirugía , Politetrafluoroetileno , Arteria Poplítea/cirugía , Estudios Retrospectivos , Vena Safena/trasplante , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Robotic-assisted abdominal wall repair (RAWR) has seen an exponential adoption over the last 5 years. Skepticism surrounding the safety, efficacy, and cost continues to limit a more widespread adoption of the platform. We describe our initial experience of 312 patients undergoing RAWR at a large academic center. A retrospective review of all patients undergoing any RAWR from July 1, 2016 to March 18, 2020 was completed. Patient specific, operation specific, and 30-day outcomes specific data were collected. Univariate analysis and multivariate logistic regression were used to assess factors associated with 30-day complications. There was a steady adoption of RAWR over the study period. A total of 312 patient were included, 138 (44%) were abdominal wall repairs and 174 (56%) were inguinal repairs. The mean age of the cohort was 54.2 years (SD 16), 69% were males, and the mean BMI was 29 kg/m2 (SD 4.8). There were two reported intraoperative events and nine operative conversions. 60 patients had at least one complication at 30-days. These include: 52 seromas, 4 hematomas, 2 surgical-site infections, 1 deep venous thrombus, and 1 recurrence at 30-days. BMI, type of hernia, and sex were not associated with complications at 30-days. The use of absorbable mesh, longer hospital stay, operative conversion, previous repair, and expert hernia surgeon were significant predictors of 30-day complications. Age, operative conversion, and previous repair were the only predictors of 30-day complications on multivariate regression. Our initial experience of 312 patients demonstrates the adoption and comparable short-term outcomes for a wide variety of robotic-assisted hernia repairs.
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Pared Abdominal , Hernia Inguinal , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Pared Abdominal/cirugía , Centros Médicos Académicos , Hernia Inguinal/cirugía , Herniorrafia/efectos adversos , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Mallas Quirúrgicas/efectos adversosRESUMEN
OBJECTIVE: To determine characteristics, outcomes, and clinical factors associated with death in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support. METHODS: A multicenter, retrospective cohort study was conducted. The cohort consisted of adult patients (18 years of age and older) requiring ECMO in the period from March 1, 2020, to September 30, 2020. The primary outcome was in-hospital mortality after ECMO initiation assessed with a time to event analysis at 90 days. Multivariable Cox proportional regression was used to determine factors associated with in-hospital mortality. RESULTS: Overall, 292 patients from 17 centers comprised the study cohort. Patients were 49 (interquartile range, 39-57) years old and 81 (28%) were female. At the end of the follow-up period, 19 (6%) patients were still receiving ECMO, 25 (9%) were discontinued from ECMO but remained hospitalized, 135 (46%) were discharged or transferred alive, and 113 (39%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%). Factors associated with in-hospital mortality were age (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.06-1.61 per 10 years), renal dysfunction measured according to serum creatinine level (aHR, 1.21; 95% CI, 1.01-1.45), and cardiopulmonary resuscitation before ECMO placement (aHR, 1.87; 95% CI, 1.01-3.46). CONCLUSIONS: In patients with severe COVID-19 necessitating ECMO support, in-hospital mortality occurred in fewer than half of the cases. ECMO might serve as a viable modality for terminally ill patients with refractory COVID-19.
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COVID-19 , Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Adolescente , Adulto , COVID-19/terapia , Niño , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
ABSTRACT Introduction: the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. Methods: a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. Results: 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). Conclusion: preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.
RESUMO Introdução: a toxina botulínica A (TBA) tem sido usada para alcançar a separação química dos componentes, com resultados favoráveis para o reparo de hérnias ventrais complexas (HVC) com ou sem perda de domínio (PD). O objetivo deste estudo é descrever nossa experiência inicial com a separação química dos componentes nos Estados Unidos. Métodos: estudo retrospectivo observacional com todos os pacientes submetidos a reparo de hérnia ventral complexa com ou sem PD entre julho de 2018 e junho de 2020. A TBA pré-operatória foi injetada em todos os pacientes, guiada por ultrassonografia, bilateralmente entre os músculos laterais para alcançar a denervação química antes da operação. Dados demográficos dos pacientes, local da hérnia, dados peri-operatórios e pós-operatórios são descritos. Resultados: 36 pacientes foram submetidos a esta técnica antes do reparo da hérnia. A idade mediana foi 62 anos (30-87). O tamanho mediano pré-operatório do defeito herniário foi 12cm (6-25) e o defeito mediano intra-operatorio foi 13cm (5-27). O volume mediano do saco herniário pré-operatório foi 1.338mL (128-14.040), o volume mediano da cavidade abdominal pré-operatório foi 8.784 (5.197-18.289) mL e a razão dos volumes foi 14%. A duração mediana da operação para aplicação da TBA foi 45 minutos (28-495). O seroma foi a complicação mais comum no pós-operatório, em oito pacientes (22%). O seguimento pós-operatório mediano foi de 43 dias (0-580). Conclusão: a separação pré-operatória de componentes com TBA é tratamento adjuvante seguro e eficaz em reparos de HVC em que aproximação da fáscia é antecipadamente desafiadora.